How much progress is expected during third year?

[Hemichordate]

I know that during third year, you're supposed to read up on your patient's problems and any issues related to the it, but it terms of clinical diagnosis abilities, how much improvement is expected over the course of a rotation?

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[futuredoctor10]

I would say if you read about your patients conditions, listen to feedback you receive, and work hard, you will likely obtain the clinical diagnosis skills required over the course of the rotation. You may not pick up on all physical exam findings the first time you see them, but that's okay just go back and relisten/redo if there is something you missed.

 

[evilbooyaa]

You should be able to make a basic DDx for most patients walking through the door. It's tough because most patients are such standard slam-dunk diagnoses, it's sometimes hard to necessiate a real DDx without it seeming like an exercise in mental masturbation. For example, a patient with PMHx CHF with 8 hospitalizations eats a cheeseburger, has SOB 1 hour after wards, non-responsive to bronchodilators. + Edema B/L, wet rales audible in bases B/L. What is his diagnosis? Well, 99% of the time it's a CHF exacerbation.

Now the part where you really should be improving as the year progresses is the Plan. What do you do for the CHF guy? Diuresis like mad, but make sure his creatinine isn't crappy. Any AMS/Ascites suggesting liver issues? Any CP (= EKG + troponins x 3)?

Focus on taking a good history, doing a proper physical, and presenting what you've done to your attendings in whatever manner they choose. Some attendings (especially if it's your first rotation) want you to go through every little thing so they know you didn't miss anything. As they trust your H&P skills more, they'll have you skip over any non-pertinent PE findings, then move on to non-pertinent history parts (do I really care that this person is sexually active with 1 partner for the past 10 years if he has a CHF exacerbation? Well, possibly if he was having sex at the time it started, but not really much more than that).

 

[45408]

You should be able to make a basic DDx for most patients walking through the door. It's tough because most patients are such standard slam-dunk diagnoses, it's sometimes hard to necessiate a real DDx without it seeming like an exercise in mental masturbation. For example, a patient with PMHx CHF with 8 hospitalizations eats a cheeseburger, has SOB 1 hour after wards, non-responsive to bronchodilators. + Edema B/L, wet rales audible in bases B/L. What is his diagnosis? Well, 99% of the time it's a CHF exacerbation.

Don't commit so early. You've described what you found after the history and physical, so yes, you should have a pretty good idea of the diagnosis by that point. However, your ability to start focusing in on the real diagnosis will be greatly improved by having the proper differential dx in mind, and then start narrowing in your questioning as you go. Back pain could be pyelonephritis, aortic dissection, or a muscle strain. Obviously, we all assign some probability to the likelihood of each situation, because a young man probably won't show up with an aortic dissection, but you might think differently if he's got a Marfanoid habitus.

This doesn't mean you have to be silly and consider all causes of fever of unknown origin when someone shows up with an indwelling Foley, positive UA, and findings of sepsis, but I've seen someone admitted for urosepsis that turned out to have Fournier's gangrene. Perhaps the diagnosis was occult on his initial presentation, but I bet that someone might have been tipped off if they'd looked. I've seen RUQ pain, history of biliary colic, tender to palpation, high white count....and it was pneumonia.

My point is that you should consider your differential as your progress through your H&P, not that you necessarily need a long list of potential but highly improbable diagnoses on your differential after you've seen the patient. Common diseases frequently present in uncommon ways. When I get a surgery consult from our cardiac unit, it's often cholecystitis, because these patients originally showed up in the ED with chest/epigastric pain.